STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHARMACY TECHNICIAN

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1 STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHARMACY TECHNICIAN APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division of Occupational and Professional Licensing (DOPL) desires to provide courteous and timely service to all applicants for licensure. To facilitate the application process, submit a complete application form including all applicable supporting documents and fees. Failure to submit a complete application and supply all necessary information will delay processing and may result in denial of licensure. The fees are for processing your application and will not be refunded. Please read all instructions carefully. Address of Record: The address you provide on this application will be your address of record. All correspondence from DOPL will be sent to that address. You are responsible to directly notify DOPL of any change to your address of record. Do not rely on a forwarding order. Social Security Number: Your social security number is classified as a private record under the Utah Government Records Access and Management Act. It is used by DOPL as an individual identifier. It is also used for child support enforcement pursuant to Subsection (3) and is mandatory pursuant to Subsection (1), Utah Code Ann., which implements 42 U.S.C. 666(a)(13). If an SSN is not provided, the application is incomplete and may be denied. SUPPORTING DOCUMENTS AND FEES: In addition to submitting a completed application, complete the following: 1. If you completed on-the-job training in Utah, submit the Affidavit of Supervising Pharmacist Responsible for Practical Training Program form (attached to this application) completed by the licensed pharmacist responsible for your on-the-job education and training program AND a Pharmacy Technician Training Hours Log (attached to this application). (See Additional Important Information below.) 2. If you completed a formal training program, submit official transcripts from your formal training program AND the Affidavit of the Official Representative of the Formal Education Program form (attached to this application) completed by the official representative of your formal education and training program AND the Pharmacy Technician hours log. (See Additional Important Information below.) NOTE: Have the school send the transcript directly to DOPL. You may also have the school send the transcript to you for inclusion with your application so long as it is in a sealed envelope, bearing the school s stamp/seal on the envelope flap. 1

2 3. If you have a license in another state and have worked 1,000 hours or more in that state, within the past two years, use the Request for Verification of License form (attached to this application) to obtain verification of licensure from that state. Request that the verifying state complete the form and mail it directly to DOPL. Additionally, submit employment records or a letter from your employer on official letterhead stating that you meet the employment criteria outlined above. 4. Submit a current copy of your national certificate issued by the Pharmacy Technician Certification Board (PTCB) or the Exam for Certification of Pharmacy Technician (ExCPT) to document your passing the national certification exam for pharmacy technicians. 5. Submit a completed take-home Pharmacy Technician Law and Rule Examination (attached to this application). 6. Bring your completed application to DOPL s offices (160 E. 300 S., Main Lobby, Salt Lake City) to complete electronic fingerprinting using DOPL s Identix equipment. OR Submit three applicant fingerprint cards (Form FD-258: white with blue lines) to be used by DOPL for a search through the files of the Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI). See Additional Important Information. 7. Submit a $ non-refundable application-processing fee, made payable to DOPL. This fee includes a $60 application fee for a pharmacy technician license, a $20 surcharge for a BCI fingerprint file search, and a $20 surcharge for a FBI fingerprint file search. ADDITIONAL IMPORTANT INFORMATION: 1. Laws and Rules Examination: Enclosed with this application is the take-home Utah Pharmacy Technician Laws and Rules Examination. Return the completed examination with your application for licensure. Do not submit it separately. The following applicable laws and rules are available on the Internet at Division of Occupational & Professional Licensing Act General Rules of the Division of Occupational & Professional Licensing Pharmacy Practice Act Pharmacy Practice Act Rules Utah Controlled Substances Act Utah Controlled Substances Act Rules 2. Current Documents: Applications, statutes, rules, and forms are occasionally changed. Go to to ensure you have the most recent version of these documents. 3. National Certification: All applicants must have passed the examination for certification of pharmacy technician with the Pharmacy Technician Certification Board (PTCB)or the Examination for the Certification of Pharmacy Technicians (ExCPT) and must submit a copy of a current national certification. 2

3 For information concerning the National Pharmacy Technician Certification Examination, contact the Pharmacy Technician Certification Board at (800) or at For information concerning the Exam for the Certification of the Pharmacy Technician (ExCPT) contact (866) or at 4. Education and Training Requirement: To be eligible for licensure, you must complete a Utah Board approved curriculum of education that includes a minimum of 180 hours of practical experience in a pharmacy supervised by a licensed pharmacist, covering at least the following topics: Legal aspects of pharmacy practice such as laws and rules governing practice. Hygiene and aseptic technique. Terminology and symbols. Pharmaceutical calculations. Identification of drugs by trade and generic names, and therapeutic classifications. Filling of orders and prescriptions including packaging and labeling. Ordering, restocking, and maintaining drug inventory. Computer applications in the pharmacy. Over the counter products, including, but not limited to, cough and cold, nutritional, analgesics, allergy, diabetic, first aid, ophthalmic, family planning, foot, feminine hygiene, and gastrointestinal preparations. Your education and training must have been completed in either an approved licensed Utah pharmacy under the supervision of a licensed pharmacist OR in an approved, formal educational setting OR by working 1,000 hours in the past year as a licensed pharmacy technician in another state that requires licensure for pharmacy technicians. 5. Fingerprint Information: All applicants are required to undergo a criminal background check and fingerprint search through the files of the Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI). Fingerprint cards that are not complete and/or properly rolled will be rejected, delaying the licensure process. To expedite the licensure process, you can obtain electronic fingerprinting at DOPL s offices (160 E. 300 S., Salt Lake City), 8:00 a.m. to 4:30 p.m., Monday through Friday, except holidays. Currently, there is no fee to roll electronic fingerprints for DOPL licensure applicants. A current government issued picture ID is required. If you are unable to obtain electronic fingerprints at DOPL s office, you must include three (3) blue fingerprint cards (Form FD-258) with your application. Fingerprint cards are supplied with the application if obtained from DOPL. If you downloaded the application from the Internet, you may obtain fingerprint cards from DOPL, the Bureau of Criminal Identification (BCI), or your local police station. To have your fingerprints rolled onto the blue fingerprint cards, you must go to BCI or a local police station. BUREAU OF CRIMINAL IDENTIFICATION (BCI) INFORMATION: Check with BCI for pricing of their services Walk-ins only; no appointments taken Fingerprinting and Photo Services are available from 8:00 a.m. 5:00 p.m., Monday - Friday except holidays 3

4 Government-issued picture ID required (driver s license, state ID, passport, etc.) Website: Phone: (801) Address: 3888 W S., Taylorsville, UT (1/2 block west of Bangerter Highway, behind McDonalds) WARNING: If information received from the Utah Bureau of Criminal Identification or the Federal Bureau of Investigation indicates that you have failed to accurately disclose your criminal history to the Division of Occupational and Professional Licensing, any pharmacy license issued to you will be immediately and automatically revoked. REVIEW OF YOUR FBI RECORD: If you wish to challenge the accuracy of the information in your FBI record, you should contact the agency that contributed the information in question. You may also direct the challenge to the FBI, Criminal Justice Information Services (CJIS) Division, Attn. SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV The FBI will forward the challenge to the respective agency. 6. License Renewal: All pharmacy licenses expire September 30 of every odd-numbered year. Unlike many other states, Utah s license renewal schedule is not based on the licensee s date of initial licensure. Under Utah s renewal system, all licenses in each profession expire as a group on the same day every two years. Therefore, the length of a licensee s first renewal cycle depends on how far into the current renewal cycle initial licensure was obtained. Each renewal cycle thereafter is for a full two years. Additionally, the fee paid with this application for licensure is an application-processing fee only. It does not include a renewal fee. Each licensee is responsible to renew licensure PRIOR to the expiration date shown on the current license. Approximately two months prior to the expiration date shown on the license, renewal information is disseminated to each licensee s last address of record, as provided to DOPL. 7. Renewal Requirements / Continuing Education: Each pharmacy technician is required to complete 20 hours of continuing education in each two-year renewal cycle. Persons licensed during the renewal period are required to complete 0.83 hours of continuing education for each month they are licensed. Of the 20 required hours, at least 1 hour must be in laws and ethics and a minimum of 8 hours must be live. All 20 hours must be approved by the Accreditation Council on Pharmaceutical Education (ACPE) and programs accredited by other nationally recognized healthcare accrediting agencies. Current certification with ExCPT or PTCB also satisfies the continuing education requirements. 8. Updating Address Information: It is your responsibility to maintain a current address with DOPL. If your address is incorrect, you will not receive renewal notices or other correspondence. Address changes can be made online at 9. Name Change: If you have been licensed by DOPL under any other name, please submit documentation of your name change (i.e. copy of a marriage license or divorce decree). 10. Ceremonial Certificate of Licensure: After obtaining your license from DOPL, you can order a Ceremonial Certificate of Licensure, printed on parchment paper with original signatures and an embossed gold seal. Order forms can be obtained at 4

5 11. Acceptable Forms of Payment: Licensure fees can be paid by check or money order, made payable to DOPL. Cash and debit/credit cards (American Express, MasterCard, and Visa) are also accepted in person at DOPL s main office but not over the telephone. 12. Submit Completed Application to: Division of Occupational & Professional Licensing By U.S. Mail P.O. Box Salt Lake City UT Division of Occupational & Professional Licensing By Express Mail 1 st Floor Lobby or In Person 160 E 300 S Salt Lake City UT Telephone Numbers: (801) (866) Toll-free in Utah 14. Fax Number: (801)

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7 APPLICATION FOR LICENSURE PHARMACY TECHNICIAN ***Please list your full legal name as it appears on your driver s license, Social Security Card, etc.*** Last Name: First Name: Middle Name: Social Security Number: - - Maiden Name: I certify under penalty of perjury that: I am a citizen of the United States and I have a valid US Driver License or US State ID. License/State ID Number: State: I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Please attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States. I am a non-citizen of the United States, who is lawfully present in the United States and I have a valid US Drivers License or US State ID. License/State ID Number: State: I am a non-citizen of the United States, who is lawfully present in the United States and I do not have a valid US Drivers License or US State ID. Please attach a legible copy of your current and valid government issued document showing evidence of authorization to work in the United States. I am a foreign national not physically present in the United States. Mailing Address: City: State: ZIP: Male Date of Birth: Phone #: Female List all other licenses, registrations, or certifications issued by any state which you now hold or have ever held in any profession. (Use additional sheets if necessary.) Profession: Issuing State: License Number: License Status: Issue Date: Profession: Issuing State: License Number: License Status: Issue Date: Profession: Issuing State: License Number: License Status: Issue Date: Profession: Issuing State: License Number: License Status: Issue Date: DO NOT WRITE IN THIS SECTION - FOR DIVISION USE ONLY License/Certificate Number: Date License/Certificate Approved: / / Approved By: Date License/Certificate Denied: / / Denied By: Reason for Denial/Other Comments: 7

8 EXAMINATION REQUIREMENT: Select one: Examination for the Certification of Pharmacy Technician (ExCPT) Date(s) Taken: / / National Pharmacy Technician Certification Examination (PTCB) Date(s) Taken: / / EDUCATION AND TRAINING: Answer yes or no. I have completed the required program of education and training for licensure as a pharmacy technician in a formal educational (college) setting. -- OR -- Name of School: Address of School: Official Program Representative: Program Start Date: / / Completed: / / Supervising Pharmacist: Name and Location of Pharmacy: Start Date of Pharmacy Training: / / Completed: / / I have completed the required program of education and training for licensure as a pharmacy technician through on-the-job training in a licensed Utah pharmacy. -- OR -- Name of Utah Pharmacy: Address of Utah Pharmacy: Utah Pharmacy License Number: Pharmacist in charge of your education and training: Start Date: / / Completed: / / I have practiced at least 1,000 hours in the past two years (endorsement). Current State of Licensure: License Number: Name of Pharmacy Technician School or Program: 8

9 UTAH PHARMACY TECHNICIAN LAWS AND RULES EXAMINATION The reference listed after each question is provided to assist you in selecting your response. The examination is not intended to be difficult. The purpose of the exam is to bring to your attention specific practice issues you need to know in order to avoid violating Utah law and rule. If you are uncertain about any of the questions listed below, please refer to the references listed. Pharmacy Practice Act, 58-17b - Pharmacy Practice Act Rule, R156-17b - Utah Controlled Substances Act, Utah Controlled Substance Act Rule, R Answer true or false for each statement. Do not leave any statement blank. Return this completed examination with your application for licensure as a Utah Pharmacy Technician. 1. Each prescription drug dispensed must be labeled with all of these items: A. name, address, and telephone number of the pharmacy B. end use date of the prescription C. filling date of the prescription D. name of the patient 2. A licensed pharmacist shall provide supervision to NO MORE than 3 licensed pharmacy technicians on duty -- or 2 licensed pharmacy technicians and 1 technicianin-training. 3. From the date of the most recent prescription filled or refilled, a patient profile shall be maintained for a minimum of 1 year. 4. In a pharmacy, a licensed pharmacy technician may assist the pharmacist in preparing prescriptions ONLY under the general supervision of the pharmacist, and the pharmacist reviews and verifies each prescription before it is given to the patient. 5. Pharmacy technicians may legally perform all of these functions: A. count and pour medications into containers and affix labels B. receive written prescription from a patient at the counter C. enter and retrieve information into and from a database or patient file D. counsel patients on over-the counter medications under the direction of the pharmacist 6. All of the following are legally required on a prescription order: A. name of the prescriber B. address of the prescriber C. name and quantity of the medication D. birth date of the patient, if a controlled substance is ordered 7. Under the Utah Controlled Substance Act, a prescription for a Schedule II controlled substance may be filled for a quantity not to exceed a one-month supply. (Continued on the next page.) 9

10 8. Unless a Schedule V prescription is renewed by the practitioner, it may not be refilled after 12 months. 9. No prescription may be written, issued, filled or dispensed for a Schedule I controlled substance. 10. A single written prescription form may contain only one controlled substance and no other prescriptions orders. 11. A Schedule III or IV controlled substance can be refilled for 5 months after the date of the original issuance. 12. A patient is taking a controlled substance according to the prescriber s instructions. She is at the pharmacy requesting an authorized refill. Before refilling the prescription, the technician and pharmacist must ensure that enough time has elapsed to allow her to consume 80% of the medication from the previous filling. 13. A prescribing practitioner gives a pharmacist an emergency oral prescription for a Schedule II controlled substance. The prescription can be filled and dispensed if the prescribing practitioner delivers the written prescription to the pharmacy within 7 working days. 14. Refusing a DOPL investigator to do an inspection during regular business hours is considered unlawful conduct. 15. Failing to report to the Division another licensee s unlawful or unprofessional conduct would be considered unprofessional conduct. 16. If a pharmacy employs an unlicensed pharmacy technician, the maximum amount that can be fined for the initial offense is $ A pharmacy technician who violates the unlawful conduct provision can be found guilty of a Class A misdemeanor. 18. Failing to provide the Division with a current mailing address within 10 business days following any change of address is considered unprofessional conduct. 19. Unlawful conduct includes using a prescription drug or controlled substance that was not legally prescribed to him by a practitioner. 20. During each renewal period, a pharmacy technician must complete 20 hours of continuing education. 21. Continuing education programs that can be counted towards the requirements for license renewal include attendance to ACPE approved live seminars and online programs, or an active and current pharmacy technician certification. (Continued on the next page.) 10

11 22. A pharmacy technician must maintain records of continuing education for 4 years after the close of the two year period to which the records pertain. 23. In Utah, a pharmacy technician must be trained in a Board approved program. If a technician-in-training does not attend an approved training program, the program will not be accepted and that person will not be eligible for license. 24. A technician-in-training in Utah must complete an approved training program, successfully pass the required examinations, and become licensed within one year from the first day of the training program. 11

12 AFFIDAVIT and RELEASE AUTHORIZATION 1. I certify that I am qualified in all respects for the license for which I am applying in this application. 2. I certify that to the best of my knowledge, the information contained in the application and its supporting document(s) is free of fraud, forgery, misrepresentation, omission of material fact; is truthful, correct, and complete; discloses all material facts regarding the applicant; and that I will update or correct the application as necessary, prior to any action on my application. 3. I authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others not specifically included in the preceding characterization, which are set forth directly or by reference in this application, to release to the Division of Occupational and Professional Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division of Occupational and Professional Licensing to properly evaluate my qualifications for licensure/certification/registration by the State of Utah. 4. I understand that it is the continuing responsibility of applicants and licensees to read, understand, and apply the requirements contained in all statutes and rules pertaining to the occupation or profession for which I am applying, and that failure to do so may result in civil, administrative, or criminal sanctions. Signature of Applicant: Date of Signature: / / 12

13 PHARMACY TECHNICIAN QUALIFYING QUESTIONNAIRE Answer yes or no for each question. Do not leave any question blank. 1. Have you ever applied for or received a license, certificate, permit, or registration to practice in a regulated profession under any name other than the name listed on this application? 2. Have you ever been denied the right to sit for a licensure examination? 3. Have you ever had a license, certificate, permit, or registration to practice a regulated profession denied, conditioned, curtailed, limited, restricted, suspended, revoked, reprimanded, or disciplined in any way? 4. Have you ever been permitted to resign or surrender your license, certificate, permit, or registration to practice in a regulated profession while under investigation or while action was pending against you by any health care professional licensing agency, hospital or other health care facility, or criminal or administrative jurisdiction? 5. Are you currently under investigation or is any disciplinary action pending against you now by any licensing agency or governmental agency? 6. Have you ever had hospital or other health care facility privileges denied, conditioned, curtailed, limited, restricted, suspended, or revoked in any way? 7. Have you ever been permitted to resign or surrender hospital or other health care facility privileges, while under investigation or while action was pending against you by any licensing agency, hospital or other health care facility, or criminal or administrative jurisdiction? 8. Is any action related to your conduct or patient care pending against you now at any hospital or health care facility? 9. Have you ever had rights to participate in Medicaid, Medicare, or any other state or federal health care payment reimbursement program denied, conditioned, curtailed, limited, restricted, suspended, or revoked in any way? 10. Have you ever been permitted to resign from Medicaid, Medicare, or any other state or federal health care payment reimbursement program while under investigation or while action was pending against you by any licensing agency, hospital, or other health care facility, or criminal or administrative jurisdiction? 11. Is any action pending against you now by Medicaid, Medicare, or any other state or federal health care payment reimbursement program? (Continued on the next page.) 13

14 12. Have you ever had a federal or state registration to sell, possess, prescribe, dispense, or administer controlled substances denied, conditioned, curtailed, limited, restricted, suspended or revoked in any way by either the federal Drug Enforcement Administration or any state drug enforcement agency? 13. Have you ever been permitted to surrender your registration to sell, possess, prescribe, dispense, or administer controlled substances while under investigation or while action was pending against you by any health care profession licensing agency, hospital or other health care facility, or criminal or administrative jurisdiction? 14. Is any action pending against you now by either the Federal Drug Enforcement Administration or any state drug enforcement agency? 15. Have you been named as a defendant in a malpractice suit? 16. Have you ever had office monitoring, practice curtailments, individual surcharge assessments based upon specific claims history, or other limitations, restrictions, or conditions imposed by any malpractice carrier? 17. Have you ever had any malpractice insurance coverage denied, conditioned, curtailed, limited, suspended, or revoked in any way? 18. If you are licensed in the occupation/profession for which you are applying, would you pose a direct threat to yourself, to your patients or clients, or to the public health, safety, or welfare because of any circumstance or condition? 19. Have you ever been declared by any court of competent jurisdiction incompetent by reason of mental defect or disease and not restored? 20. Have you ever had a documented case in which you were involved as the abuser in any incident of verbal, physical, mental, or sexual abuse? 21. Have you been terminated from a position because of drug use or abuse within the past five (5) years? 22. Are you currently using or have you recently (within 90 days) used any drugs (including recreational drugs) without a valid prescription, the possession or distribution of which is unlawful under the Utah Controlled Substances Act or other applicable state or federal law? 23. Have you ever used any drugs without a valid prescription, the possession or distribution of which is unlawful under the Utah Controlled Substances Act or other applicable state or federal law, for which you have not successfully completed or are not now participating in a supervised drug rehabilitation program, or for which you have not otherwise been successfully rehabilitated? 24. Do you currently have any criminal action pending? (Continued on the next page.) 14

15 25. Have you pled guilty to, no contest to, entered into a plea in abeyance or been convicted of a misdemeanor in any jurisdiction within the past ten (10) years? Motor vehicle offenses such as driving while impaired or intoxicated must be disclosed but minor traffic offenses such as parking or speeding violations need not be listed. 26. Have you ever pled guilty to, no contest to, or been convicted of a felony in any jurisdiction? 27. Have you, in the past ten (10) years, been allowed to plea guilty or no contest to any criminal charge that was later dismissed (i.e. plea in abeyance or deferred sentence)? 28. Have you ever been incarcerated for any reason in any federal, state or county correctional facility or in any correctional facility in any other jurisdiction or on probation/parole in any jurisdiction? If you answered yes to questions 24, 25, 26, 27, or 28 above, you must submit a complete narrative of the circumstances that occurred for EACH and EVERY conviction, plea in abeyance, and/or deferred sentence. You must also attach copies of all applicable police report(s), court record(s), and probation/parole officer report(s). If you are unable to obtain any of the records required above, you must submit documentation on official letterhead from the police department and/or court indicating that the information is no longer available. If you have formally expunged a criminal record as evidenced by a court order signed by a judge, you do not need to disclose that criminal history. Expungement orders must be sent to the Bureau of Criminal Identification and the FBI to enable the expungement to be completed and the criminal history eliminated from the records. If you answered yes to any of the above questions, enclose with this application complete information with respect to all circumstances and the final result, if such has been reached. A yes answer does not necessarily mean you will not be granted a license; however, DOPL may request additional documentation if the information submitted is insufficient. 15

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17 AFFIDAVIT OF APPLICANT S EDUCATION AND TRAINING I declare under penalty of perjury as follows: I am the person described and identified in this application. I have completed a program of education and training in either a formal educational setting or on-thejob training in an approved licensed Utah pharmacy that consisted of combined didactic and clinical training, with at least 180 hours consisted of clinical, hands-on training. The program included at a minimum the following topics: 1. Legal aspects of pharmacy practice such as laws and rules governing practice. 2. Hygiene and aseptic technique. 3. Terminology, abbreviations and symbols. 4. Pharmaceutical calculations. 5. Identification of drugs by trade and generic names, and therapeutic classifications. 6. Filling of orders and prescriptions including packaging and labeling. 7. Ordering, restocking, and maintaining drug inventory. 8. Computer applications in the pharmacy. 9. Over the counter products, including, but not limited to, cough and cold, nutritional, analgesics, allergy, diabetic, first aid, ophthalmic, family planning, foot, feminine hygiene, and gastrointestinal preparations. The program of education and training is outlined in a written plan that has been approved by the Utah Pharmacy Board, and included a final examination covering at a minimum the topics listed above. Signature of Applicant: Date of Signature: / / 17

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19 Division of Occupational and Professional Licensing 160 East 300 South, P.O. Box Salt Lake City, Utah AFFIDAVIT OF THE OFFICIAL REPRESENTATIVE OF THE FORMAL EDUCATION PROGRAM I declare under penalty of perjury as follows: I attest that the applicant has successfully completed a program of education and training in a formal educational setting. I attest that the program consisted of included at a minimum the following topics: hours of didactic and at least 180 hours of practical training that 1. Legal aspects of pharmacy practice such as laws and rules governing practice. 2. Hygiene and aseptic technique. 3. Terminology, abbreviations and symbols. 4. Pharmaceutical calculations. 5. Identification of drugs by trade and generic names, and therapeutic classifications. 6. Filling of orders and prescriptions including packaging and labeling. 7. Ordering, restocking, and maintaining drug inventory. 8. Computer applications in the pharmacy. 9. Over the counter products, including, but not limited to, cough and cold, nutritional, analgesics, allergy, diabetic, first aid, ophthalmic, family planning, foot, feminine hygiene, and gastrointestinal preparations. I attest that the program of education and training is outlined in a written plan that shall be available to DOPL and the Board upon request. Applicant s Name: Official Program Representative: Signature of Official Program Representative: Date: / / Name of School: Address of School: Supervising Pharmacist s Name: Telephone: License Number: Supervising Pharmacists Signature: Date of Signature: / / Name of Pharmacy Where Practical Experience Took Place: Utah Pharmacy License Number: 19

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21 Division of Occupational and Professional Licensing 160 East 300 South, P.O. Box Salt Lake City, Utah AFFIDAVIT OF SUPERVISING PHARMACIST RESPONSIBLE FOR ON-THE-JOB TRAINING PROGRAM I declare under penalty of perjury as follows: I attest that the applicant has successfully completed a curriculum of education and practical training program approved by the Pharmacy Board in an approved licensed Utah pharmacy. I attest that the program consisted of didactic training hours with a supervising pharmacist and at least 180 clinical training hours, covering at least the following topics: 1. Legal aspects of pharmacy practice such as laws and rules governing practice. 2. Hygiene and aseptic technique. 3. Terminology, abbreviations and symbols. 4. Pharmaceutical calculations. 5. Identification of drugs by trade and generic names, and therapeutic classifications. 6. Filling of orders and prescriptions including packaging and labeling. 7. Ordering, restocking, and maintaining drug inventory. 8. Computer applications in the pharmacy. 9. Over the counter products, including, but not limited to, cough and cold, nutritional, analgesics, allergy, diabetic, first aid, ophthalmic, family planning, foot, feminine hygiene, and gastrointestinal preparations. I attest that the program of education and training is outlined in a written plan that shall be available to DOPL and the Board upon request. Applicant s Name: Supervising Pharmacist s Name: Signature of Supervising Pharmacist: Date of Signature: / / Supervising Pharmacist s License Number: Utah Pharmacy in which Education and Training was Received: Utah Pharmacy License Number: 21

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23 Division of Occupational and Professional Licensing 160 East 300 South, P.O. Box Salt Lake City, Utah Fax: (801) REQUEST FOR VERIFICATION OF LICENSE (Use this form to verify licensure from another state, if applicable.) PART 1 - TO BE COMPLETED BY THE APPLICANT: Complete the first section of the form. Request that the verifying state complete the form and mail it directly to DOPL or return it to you for submission with your application. Applicant s Name: Street Address: City: State: Zip: I am requesting licensure in the state of Utah as a: I am/have been licensed in your state under the name: My Social Security Number is: My Date of Birth is: My license number in your state is/was: I have enclosed the necessary license verification fee in the amount of: Signature of Qualifier: Date of Signature: / / (Continued on the next page.) 23

24 PART 2 - TO BE COMPLETED BY THE VERIFYING AGENCY: Please furnish the information requested, sign and verify the document, and place the completed form in an envelope, seal the envelope and provide it to the applicant in person or by mail. The qualifier will include the verification of licensure with his/her Utah application. Thank you. Name of Verifying State: Name of Licensee (as it appears in verifying state s records): Name of Qualifying Person: Classification of License Issued: License Number: Original Date of Licensure: Current Status: Expiration Date: / / Continuously Licensed: Licensed By: Yes No, please explain: Exam, Type: Date: / / Endorsement, From What State Examination Scores: Education Required For Licensure: Disciplinary Action or Pending Disciplinary Action: Signature: No Yes, please provide certified copies of all Petitions, Orders, etc. Title: Agency: Date of Signature: / / (SEAL) 24

25 Division of Occupational and Professional Licensing 160 East 300 South, P.O. Box Salt Lake City, Utah PHARMACY TECHNICIAN TRAINING HOURS LOG ALL TECHNICIANS IN TRAINING MUST COMPLETE THIS LOG. Record your training hours only. DO NOT include time worked as a clerk or support personnel. Record your total hours for each day (i.e. 6 hrs.) DO NOT list the schedule that you worked (i.e. 8:00 2:00). If you are working at more than one pharmacy, an hours log is required for each pharmacy. (Make additional copies as necessary.) Technician Name: NOTE: The technician in training has one year from the beginning date to complete the required training, testing, and application for licensure. Day Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

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27 TO BE COMPLETED BY PHARMACISTS DOING THE TRAINING: Pharmacy Name: Address: Technician s Name: The above named technician was observed under my supervision from / / to / / and worked the hours shown on the log above. Total Hours of Pharmacy Practice Experience: Name of Approved Curriculum: Pharmacist s Name: License Number: NOTE: Continuity of Education is essential for the Technician-in-training in order to produce a valued and knowledgeable pharmacy technician. Therefore, the Board and the Division require that a pharmacist in good standing consistently supervises training and that all elements of the scope of practice are addressed at one training site. If additional training sites are used, such as a hospital pharmacy, please assure that all aspects of the scope of practice are addressed at each learning site and are recorded on separate logs. I attest that the student named on this log completed all of the requirements related to technician practice as outlined in the approved curriculum of study and all outcomes of the practicum were taught and the hours accumulated at only this location. legal aspects of pharmacy practice such as laws and rules governing practice hygiene and aseptic technique terminology and symbols pharmaceutical calculations identification of drugs by trade and generic names, and therapeutic classifications filling of orders and prescriptions including packaging and labeling ordering, restocking, and maintaining drug inventory computer applications in the pharmacy over the counter products, including, but not limited to, cough and cold, nutritional, analgesics, allergy, diabetic, first aid, ophthalmic, family planning, foot, feminine hygiene, and gastrointestinal preparations Pharmacist s Signature Pharmacist s Signature Pharmacist s Signature Date: / / Date: / / Date: / / TO BE COMPLETED BY TECHNICIAN: I have reviewed the information included in this document and agree that it accurately covers my technician training experience. Technician Signature: Date of Signature: / / 27